Self Evaluation Test

Is LASIK right for your eyes? You can’t guess at this and neither can your doctor, so a thorough exam and consultation is essential. To know if you’re in the LASIK ballpark take this quick self-evaluation.

1. Do you wear contact lenses or glasses most of the time?*

Contacts

Glasses

Neither

2. Without glasses or contacts, do you have trouble seeing far away or up close?*

Far Away

Up Close

Both

3. How interested are you in being able to play sports without glasses and contacts?*

It's very important to me NOT to wear glasses for activities such as sports.

It's not important to me. I do not mind wearing glasses.

4. How old are you?*

18-21

22-44

45-64

65+

Do you wear glasses or contacts while driving?*

Yes

No

Can you read the paper without reading glasses?*

Yes

No

Can you read the paper while wearing these without using a bifocal lens or reading glasses?*

Yes

No

Do you want to see well enough up close to read without reading glasses?*

It's not important to me. I do not mind wearing reading glasses to see things up close.

It's very important to me NOT to wear reading glasses.

5. If you wear contacts have you experienced any of these complications (Select more than one if necessary.)*

6. Would the quality of your life improve if you were less dependent on glasses and contacts?*

Yes

No

Maybe

7. Over 98% of LASIK patients see 20/40 or better after surgery. The results of LASIK laser vision correction have been tremendous for literally millions of people. Despite the amazing safety and results of this procedure, there are associated risks that are comparable to those risks associated with contact lens wear. Are you willing to discuss these risks with our LASIK coordinator?*

Yes

No

Name*

FirstLast

Email*

Phone*

Employer

8. After careful examination and consultation with our previous patients, many have been told by others that they are not a candidate when in fact they are. Have you ever been told you are not a candidate?*

Yes

No

9. Are you aware that you may be eligible for advance surface ablation (ASA) instead of LASIK ? ASA utilizes the same advanced laser technology but does not require making a corneal flap.

10. If you have an exceptionally high prescription, and/or you are over age 50, you may want to consider refractive lens exchange (RLE). The advantages for older individuals is that RLE prevents formation of cataracts later and may allow for both near and distance vision without the need for glasses. Would you be interested in this procedure?